Purpose : We investigated the effectiveness of an Enhanced Recovery After Surgery Protocol for colorectal surgery, which is designed to let patients recognize their quick recovery, in terms of duration of postoperative hospital stay. Methods : Sixty-six consecutive patients who underwent colorectal surgery between August 2011 and October 2012 in our facility were prospectively analyzed. Considering that patients could be aware of their own quick recovery, a soymilk based, seasoning adjusted, low-fat, low-residual hospital diet was originated in our facility for easy feeding, and we served them during the perioperative period. A pedometer was lent to them so as to manage perioperative activities by themselves. Another 55 patients who were managed by conventional method befere ERAS protocol were retrospectively analyzed as a control. Results : The postoperative hospital stay was 5 days in the ERAS group versus 8 days in the conventional in median group (p<0.01). There was no significant difference between the two groups in morbidity. Pedometer took a feasible role to ensure the maintenance in postoperative activities. Conclusions : Enhanced Recovery After Surgery Protocol for colorectal surgery, which is designed to let patients recognize their quick recovery, contributed to shorten postoperative hospital stay.

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A retrospective analysis was performed to evaluate the usefulness of laparoscopic immediate appendectomy (IMA) and interval appendectomy (IA) in children with acute appendicitis. There were 510 children diagnosed as having acute appendicitis and 485 patients (95.1%) of them were treated by IMA. Laparoscopic IMA was performed in 420 (86.6%) of these 485 patients, and conversion to conventional open surgery was necessary in three patients. The incidences of surgical complications were 4.0% in patients with uncomplicated appendicitis and 19.3% in those with complicated appendicitis. Laparoscopy-related complications were observed in the early days after the introduction of laparoscopic appendectomy. On the other hand, IA was performed in 25 (4.9%) out of 510 patients. Although abdominal pain recurred during the interval waiting IA, nonoperative treatments were successful and delayed laparoscopic appendectomy was performed in all these patients. The final diagnoses included carcinoid tumor of the appendix and Meckel's diverticulitis in one patient, respectively. There were no surgical complications except intraoperative minor injuries of the intestinal serosa. We conclude that laparoscopic appendectomy is a standard option of IMA in children with acute appendicitis and nonoperative treatment followed by IA is effective in evading major surgical complications caused by IMA in children with appendiceal mass or abscess.

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Laparoscopic fenestration that is considered to be appropriate for benign simple liver cysts due to its minimal invasiveness has been performed. Furthermore single incision laparoscopic surgery has recently been highlighted due to its high cosmetic benefit. This paper deals with our experience with six cases of symptomatic simple liver cysts in which we performed single incision laparoscopic fenestration.
Subjects and methods : All six patients enrolled in this study had some symptoms such as abdominal distension, and their liver cysts were 98 - 200 mm in maximum diameter. All cysts had projected on the surface of the liver, and could perfectly be operated on via approach from the navel only because they were located on the subhepatic space.
Results : The cysts contained 300 - 1,400 ml of serous liquid. No postoperative complications occurred. The procedure was excellent from a cosmetic viewpoint of the surgical wound, and all the patients were highly satisfied with the procedure.
Conclusions : Single incision laparoscopic fenestration for simple liver cysts is an excellent operative procedure in terms of maintaining both radicality and minimal invasiveness. This procedure can be the alternative to the conventional fenestration for symptomatic simple liver cysts.

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Objective : We aimed to assess an intraoperative vessel detection technique using the Doppler ultrasonic (Doppler US) flowmeter for laparoscopic cholecystectomy (LC).
Methods : A total of 13 consecutive patients who underwent LC by the reduced port technique at our hospital were evaluated for right hepatic artery (RHA) and cystic artery (CA), using enhanced computed tomography (CT) preoperatively and the Doppler US flowmeter intraoperatively. We analyzed the flow speed and waveforms of each artery, as detected by the Doppler US flowmeter. The detection rate with the Doppler US flowmeter and that with CT were compared for each artery.
Results : RHA was detected by CT in 12 patients ; the Doppler US flowmeter was used for RHA detection in all the patients. CA was detected by CT in 8 patients and by the Doppler US flowmeter in 12 patients. The maximum flow speed (mean ± SD) was 30.3 cm/s in patients with RHA and 8.13 cm/s in those with CA (p < 0.001). The difference between the waveform pattern of the RHA and that of CA acquired by the Doppler US flowmeter was evident. Moreover, no postoperative complications were noted in any patient.
Conclusions : The vessel detection technique using the Doppler US flowmeter was relatively simple and easy to perform for RHA and CA during LC. Therefore, we suggest that this procedure be implemented to improve the safety of LC.

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A 53-year-old man was referred to our hospital with the chief complaint of pain in the right femur. Computed tomography (CT) showed a nodular lesion about 6 cm in diameter located in the left thyroid lobe, and osteolytic change in the second thoracic vertebra and the right femur. Fine needle cytology of the nodular lesion in the left thyroid lobe revealed no atypical thyroid cells. The right femur was broken, and an operation was performed and bone metastasis of thyroid carcinoma was diagnosed based on a bone biopsy. Local radiotherapy was performed for the metastases first, and then the patient underwent total thyroidectomy and D1 lymph node dissection. Follicular variant of papillary thyroid microcarcinoma with multiple bone metastases was conclusively diagnosed. One year after the operation, the treatment with bisphosphonate zoledronic acid at a dosage of 4 mg administered once every 4 weeks was performed, and the administration of I-131 was given twice. Multimodal treatment for multiple bone metastases have been demonstrated to provide improvement in activities of daily life (ADL) and QOL of patients.

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We report the case of a 72-year-old woman, who was being followed after having breast cancer surgery. She had a history of thyroidectomy for thyroid cancer 39 years prior. A 7.8-mm nodule in the left lung was found on computed tomography, and on FDG-PET, accumulation was seen in the mass. Since a malignant tumor was suspected, it was resected. On pathology, a pulmonary metastasis of papillary thyroid cancer was diagnosed. A solitary pulmonary metastasis of papillary thyroid cancer is relatively rare. Furthermore, the patient had a long time interval between resection of the primary lesion and the appearance of the metastasis ; this made it difficult to preoperatively diagnose the metastasis as a metastasis of the thyroid cancer.

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A 48-year-old woman with invasive ductal carcinoma of the left breast underwent breast-conserving surgery and axillary dissection ; 19 months after surgery, she developed local recurrence. Subsequently, she underwent mastectomy and received endocrine therapy and chemotherapy. At 47 years of age, she developed pleural metastasis, which directly invaded the vertebrae as well as the right supraclavicular and right axillary lymph nodes. In addition, liver metastasis was observed. To avoid acute transverse myelopathy, the patient received radiation therapy to the vertebrae and the right supraclavicular and right axillary lymph nodes followed by paclitaxel plus bevacizumab administration. After 2 courses of paclitaxel plus bevacizumab, we observed a remarkable shrinkage of the vertebral tumor, and skin necrosis was observed in the right supraclavicular and right axillary region ; in contrast, the liver metastasis had increased in size. After discontinuation of the combination therapy, the patient died of blood loss from the axillary skin defect. This wound healing complication might have arisen because of the synergistic effects of paclitaxel plus bevacizumab and irradiation.

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We report a case of pseudoangiomatous stromal hyperplasia (PASH) of the breast. During a medical checkup 6 years ago, a 51-year-old woman was diagnosed with a mass in her left breast, which was suspected to be fibroadenoma according to the findings from the aspiration biopsy cytology ; she was recommended to undergo observation to monitor her progress. The patient visited our hospital because, as assessed by mammography, the mass continued to grow in size. A 23-mm movable mass was located in the A area of the left breast. Although mammography and ultrasonography revealed no malignant findings, we performed an excisional biopsy because the mass increased in size. The tumor was a solid, grayish-white, elastic-hard lesion measuring 35×24×15 mm. Pathological examination revealed a collection of glands in an increased amount of stroma. The stroma around the glands exhibited slit-like spaces lined with spindle cells. These stromal spindle cells were immunohistochemically positive for CD34 and vimentin and negative for Factor VIII, thus leading to the histopathological diagnosis of the lesions as PASH.

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Rectal metastasis from breast cancer is comparatively rare. We report a case of rectal metastasis from breast cancer diagnosed 17 years after breast surgery. The patient was a 67-year-old woman who underwent modified radical mastectomy with axillary lymph node dissection for left breast cancer 17 years earlier. She complained of constipation and visited the previous clinic. She was referred to our hospital since rectal stenosis was detected. Barium enema showed a narrowing segment encircling the lower rectum. Colon fiber showed reddish mucosa without ulcerated and elevated lesions in the rectum. Computed tomography revealed wall thickening of the rectum. A needle biopsy of the rectum was performed. The immunohistopathological analysis demonstrated the lesion to be rectal metastasis of breast cancer, invasive lobular carcinoma. Hormone therapy with letrozole was started and gave a relief of the symptom. The lesion has been well controlled for two years.

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An 80-year-old man received endocrine therapy after being diagnosed with prostate cancer(T3N1M1 Stage IV). A right breast tumor was detected 3 years and 9 months after start of treatment by palpation, mammography, and ultrasonography. He underwent a partial mastectomy, and the pathological diagnosis was invasive ductal carcinoma. A left breast tumor was detected 11 months after detection of the right breast tumor by palpation, mammography, and ultrasonography. A wide excision was performed, and although the patient was pathologically diagnosed with invasive ductal carcinoma, both tumors lacked intraductal component. Cells of both tumors demonstrated prostate-specific antigen immunoreactivity, but did not express estrogen receptor (ER), progesterone receptor (PgR), gross cystic disease fluid protein-15 (GCDFP-15), cytokeratin (CK)-7 and CK20. While prostate cancer with metastases to the breast can be difficult to diagnose, immunostaining was useful in demonstrating ER, PgR, human epidermal growth factor receptor-2, GCDFP-15, CK7, and CK20 immunoreactivity.

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A 75-year-old man visited a neighboring hospital because of eyelid ptosis, double vision, and feeling of something wrong around the mouth was found to be anti-acetylcholine receptor (anti-AchR) antibody positive and Tensilon test positive. Chest CT scan showed a 56 × 30 mm tumor at the anterior mediastinum. Thymoma associated with myasthenia gravis was thus diagnosed. In addition, close examinations for an increased blood sugar level in a short time showed strong positivity for serum anti-glutamic acid decarboxylase (anti-GAD) antibody, 5,100 u/ml, for that the patient was considered also to have type 1 diabetes mellitus. Extended thymectomy was performed for the thymoma associated with myasthenia gravis that was clarified to be in Masaoka's stage III invading the left brachiocephalic vein. The histopathological diagnosis was type B1 thymoma. It was GAD antibody positive on immunohistochemical stainigs. Postoperative introduction of steroids resulted in disappearance of myasthenia gravis and decreasing tendencies in both anti-AchR antibodies and anti-GAD antibodies, however, no improvement in diabetes mellitus has been confirmed.
Although thymomas are often associated with a variety of autoimmune disorders including myasthenia gravis, those associated with type 1 diabetes mellitus, the representative autoimmune disease, are rare. This paper deals with our case of thymoma with anti-GAD antibody positive myasthenia gravis, together with previous cases reported in Japan so far.

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A 27-year-old man with a history of Kawasaki disease presented with chest discomfort. A coronary angiography (CAG) showed coronary aneurysms at the proximal portion of the left anterior descending artery (LAD) without significant stenosis, and complete obstruction of the proximal right coronary artery. We performed off-pump coronary artery bypass grafting (OPCAB) from either side of the internal thoracic artery (ITA). Postoperative CAG revealed flow competition in the left ITA graft. However, 3 years after the surgery, the patient experienced complete occlusion of the diagonal branch, but the left ITA graft reopened the occlusion. Thus, we believe that even in the absence of significant stenosis associated with coronary aneurysms, arterial grafting may prevent fatal myocardial infarction.

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The patient was an 89-year-old man who underwent open surgery with a bifurcated graft for a ruptured abdominal aortic aneurysm 3 years prior. An endovascular aortic repair (EVAR) was performed on a proximal anastomosis pseudoaneurysm that was diagnosed 1 year after the operation. 1 year after the EVAR, the patient developed hematemesis and a backache. Emergency CT showed an expanding pseudoaneurysm, and an emergency operation was performed. There was a strong adhesion between the small intestine and the pseudoaneurysm, so they were removed at the same time. On pathology, a graft-enteric fistula was found. Because of a coagulation disorder resulting from the long operation and hypothermia, the patient developed a bleeding tendency. A large amount of gauze was used to pack around the anastomosis of the graft ; the abdominal wall was closed with a vinyl sheet because it was impossible to close the abdominal wall only using the skin. After the operation, we monitored intra-urinary bladder pressure to prevent abdominal compartment syndrome. Pseudoaneurysm is a relatively rare complication, and the mortality is very high if it ruptures. Therefore, periodic follow up is recommended for the early detection of its expansion.

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An 81-year-old man who had undergone a left lung resection for primary lung cancer and lung aspergillosis, presented to an emergent room of our hospital with loss of consciousness. He was diagnosed with right tension pneumothorax. After emergent chest drainage he recovered conscious. Two days after the onset of pneumothorax, high fever occurred and the pleural effusion from the chest tube became turbid. Methicillin-resistant Staphylococcus aureus was detected from the pleural effusion and he was diagnosed with acute empyema. He improved with antibiotics and thoracoscopic drainage. Pneumothorax sometimes induces acute empyema one week after the onset. Our case is rare because it took only two days from the onset of pneumothorax to the development of empyema.

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A 62-year-old woman was transferred to our emergency clinic with massive abdominal free air that had been detected by computed tomography at another hospital. She had a history of treatment for autoimmune hepatitis, adrenal function insufficiency, and diabetes >10 years. Although she complained of slight abdominal fullness, no spontaneous pain, tenderness, or muscular defense was observed.
The hematological study revealed elevated inflammatory reaction and hepatobiliary-pancreatic enzymes. Gastrointestinal endoscopy was performed to establish the diagnosis, but detected no perforation, ascites, or peritonitis. Exploratory surgery was performed to establish the diagnosis, but also did not uncover ascites, perforation, or peritonitis. The patient's postoperative course was uneventful and she was discharged from the hospital on postoperative day 13.
The patient was diagnosed with pneumoperitoneum of idiopathic origin with no apparent organic changes, which is characteristic of the retention of massive abdominal free air.

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A 71-year-old male who underwent subtotal esophagectomy with retromediastinal gastric tube reconstruction for thoracic esophageal cancer was seen at our hospital because of nausea about 9 months after the operation. A chest computed tomography (CT) scan disclosed intestine prolapse into the left thoracic cavity. He was diagnosed with bowel obstruction due to a diaphragmatic hernia and an emergency operation was performed. Intraoperative findings included enlargement of the esophageal hiatus during the previous surgery, which behaved as a hernia orifice ; and through the orifice a small intestine had prolapsed into the left thoracic cavity and entirely necrotized. The about 260-cm long affected intestine was dissected while the esophageal hiatus was closed. Nausea appeared again after another 6 months. Chest X-ray detected bowel gas in the left thoracic cavity and another emergency surgery was conducted for recurrence of the diaphragmatic hernia. The esophageal hiatus had no adhesion, and the transverse colon had prolapsed into the left thoracic cavity. No clear signs of necrosis were observed. The esophageal hiatus was closed with non-absorbable suture and covered with the greater omentum. Diaphragmatic hernia after esophageal cancer surgery is a rare but serious complication because delayed diagnosis can cause bowel necrosis. Such a complication had recurred in this case. We here present this case, together with a review of the literature from various standpoints including probable causes of the recurrence.

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Reports of diaphragmatic hernia associated with radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) are rare. We report 2 cases of diaphragmatic hernia that developed after RFA for HCC. Case 1 involved a 65-year-old man who had undergone percutaneous RFA for HCC located in the S5 and S7 areas. Three years later, he underwent surgery from the abdominal cavity side based on the diagnosis of right diaphragmatic hernia made by another hospital. One year later, the right diaphragmatic hernia recurred, necessitating the performance of video-assisted thoracic surgery at our hospital. The defect of the diaphragm was covered with mesh. Case 2 involved a 73-year-old woman who had undergone percutaneous RFA for HCC located in the S7 area. Subsequently, she underwent 3 sessions of RFA for HCC localized in the S3, S1, and S4 areas. Seven years after the first RFA, right diaphragmatic hernia occurred, and we performed surgery via thoracotomy. The defect of the diaphragm was repaired by direct suture. The thoracotomic approach may be a safe and useful option for the treatment of diaphragmatic hernia after RFA.

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Spontaneous esophageal rupture is a disorder in which all the layers of the esophageal wall rupture due to a rapid increase in intra-esophageal pressure ; this event is fatal when it results in mediastinitis or empyema or when diagnosis and treatment are delayed. We report a case of spontaneous esophageal rupture with a concomitant hiatal hernia. The patient was a 67-year-old woman. After postprandial bloody vomiting, she experienced the onset of thoracodorsal pain and was transported to our hospital. Contrast enhanced CT showed findings raising suspicion of esophageal perforation along with a mixed type esophageal hiatal hernia. Most spontaneous esophageal rupture cases have perforations from the lower thoracic esophagus to the mediastinum and thoracic cavity and require thoracotomy. In this patient, no perforation occurred in the mediastinum or thoracic cavity ; a perforation did, however, occur locally in the intraperitoneal direction in the hernia sac. As it was the opening of an esophageal hiatus resulting from esophageal hiatal hernia, the visual field in the mediastinum was good even with the transabdominal approach, allowing treatment with laparotomy. As the sites and forms of hiatus may be different in patients with spontaneous esophageal rupture where anatomical changes such as esophageal hiatal hernia are present, it is important to select appropriate surgical procedures including the optimal method of approach.

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A 26-year-old woman with a previous history of hyperphagia developed vomiting and abdominal pain after overeating at dinner. On the next morning she was seen at our hospital because of persisting abdominal pain. The abdomen remarkably distended but there were no peritoneal signs. Abdominal CT scan showed retention of massive food residue in the abdomen and gastric dilatation was confirmed. No intraabdominal free air and ascites were seen. A transnasal gastric tube was placed with the diagnosis of acute gastric dilatation, but no discharge from the gastric tube occurred and the patient had difficulties even in vomiting. Her condition rapidly took downhill course after a worsening of abdominal pain 14 hours after admission. Re-examination with CT showed intra-abdominal free air and ascites. Perforation of the digestive organ was diagnosed and emergency laparotomy was performed. During the surgery we confirmed about 8,800 ml of residual foods in the abdominal cavity, extensive necrosis from the fundus to the body of stomach, and a huge perforation at the posterior wall of the gastric body. The blood flow was kept intact from the cardiac part to the lesser curvature as well as at the pyloric part of the stomach. The necrotized gastric wall was resected and the anterior and posterior wall margins were closed by suture so as to form the lesser curvature side gastric tube. After the operation the patient developed multiple organ failure and intra-abdominal abscess, but finally she was discharged from our hospital on independent gait.
We present a case of acute gastric dilatation due to overeating that caused gastric necrosis and gastric perforation.

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We report a case of hepatic abscess caused by a fish bone penetrating the gastric wall.
A 72-year-old man was admitted to our hospital because of high fever and malaise. Abdominal ultrasonography and abdominal CT scan showed a 3.5-cm sized abscess with strong internal echoes like a needle in the lateral segment of the liver. Gastric endoscopy revealed mild edema and erosion like findings on the lesser curvature at the angular incisure. Hepatic abscess due to a foreign body, especially a fish bone, penetrating the stomach was diagnosed. Following improvement of the hepatic abscess by conservative therapy including administration of antibiotics, removal of the foreign body was performed under laparoscopy. The foreign body was fish bone. The postoperative course was satisfactory without noteworthy complications.
Few cases of hepatic abscess caused by fish bones penetrating the gastric wall have been reported. In this case CT examination was very helpful to make the diagnosis and laparoscopic surgery, which is minimally invasive and enables us to magnify the lesion, was useful to remove the foreign body.

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A 71-year-old woman underwent a distal gastrectomy for gastric cancer two years ago. The tumor was Stage IIIB composed of T3, N2, M0 and poorly differentiated adenocarcinoma (non-solid type) histologically.
TS-1 100 mg was given as postoperative adjuvant chemotherapy for 6 months. Abdominal computed tomography (CT) scan 25 months after gastrectomy revealed left adrenal metastasis, 30 mm in size. Despite three courses of chemotherapy with TS-1, the size of the adrenal metastasis increased to 35 mm. Positron emission tomography (PET) and CT showed accumulation with a standardized uptake value (SUV) only in the left adrenal metastasis. We diagnosed her as having left adrenal metastasis only, and perfomed a left adrenectomy. Histological examination revealed adrenal metastasis from gastric cancer. The patient did well without recurrence or metastasis for 10 months. We report a rare case of resected adrenal metastasis from gastric cancer.

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A 73-year-old woman who was receiving dabigatran to prevent thrombosis from atrial fibrillation, was transferred to our hospital because of unstable vital signs. An enhanced computed tomography (CT) showed haemoperitoneum and aneurysms in the gastroepiploic artery area. An emergency abdominal angiography depicted two segmental aneurysms at the right gastroepiploic artery. We performed a transcatheter arterial embolization for hemostasis of the ruptured aneurysms. Afterward, the clinical course was stable, so that anticoagulation therapy was resumed on the following day, resulting in discharge on the 6^th day. We discuss here a therapeutic strategy for the aneurysm in the gastroepiploic artery.

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A 75-year-old woman developed advanced gastric cancer with multiple liver metastases (S2, S3). After docetaxel (DOC)/S-1 treatment, the liver metastases were reduced in size. Subsequently, in November 2011 the patient had a proximal gastrectomy, a left lateral segmentectomy, and a D2 dissection. On histopathology, no cancer was found in the resected stomach. The primary tumor biopsy tissue obtained before chemotherapy and the resected liver tissue were both positive for HER2 (IHC 2+, FISH positive). In March 2012, despite postoperative S-1 therapy, the woman's CEA and CA19-9 levels increased, and the abdominal CT showed liver metastasis (S7). Trastuzumab (Tmab) and paclitaxel (PTX) were added, the liver metastasis increased in size. Abdominal CT showed no new lesions ; therefore, a posterior segmentectomy was performed in September 2012. The resected lesion was negative for HER2 (IHC 0, FISH negative).

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A 68-year-old male with a past medical history of systemic lupus erythematosus was seen due to epigastric and back pain. On physical examination, only epigastric tenderness was found. Abdominal CT showed a thickened fourth portion of the duodenal wall, a dirty fat sign, and free air in the anterior of the left renal vein. An emergency operation was performed under the diagnosis of perforation of a duodenal neoplasm. A laparotomy in corporating the Kocher maneuver, displacement of the distal pancreas, and cutting of the ligament of Treitz did not reveal the mass or the perforation. Intraoperative endoscopy was done, and a perforated duodenal diverticulum due to a fishbone was found. The diverticulum was excised. The patient was discharged on the 19th post op day. We report a rare case of a perforated fourth portion of the duodenal diverticulum, caused by a fishbone which was diagnosed on intraoperative endoscopy.

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Giant duodenal ulcer perforation is a complicated disease with high morbidity and mortality under conventional treatment strategy. We report a case of giant duodenal ulcer perforation treated by omental plugging and biliary drainage. The patient was a 61-year-old woman who was admitted to the hospital for back pain and anorexia after nonsteroidal anti-inflammatory drug (NSAID) use. Laboratory data showed leukocytosis (21,900/μl) and a high CRP level (22.39 mg/dl). Abdominal computed tomography (CT) revealed perforation of the duodenum and a confined abscess. The operative findings were giant perforation (5.5 × 3.5cm) of the duodenum and an abscess with biliary perforation. Because of severe adhesion after the radical hysterectomy and left hepatectomy, omental plugging and biliary drainage were performed. Although leakage was observed after operation, it improved rapidly and there was no duodenal stenosis. Omental plugging and biliary drainage are low invasive procedures and may be useful for high risk patients.

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A 59-year-old man had tarry stools since 2007. Because upper and lower gastrointestinal endoscopy revealed no remarkable findings, the patient was followed. In June 2009, a type 2 tumor occupying almost the entire circumference of the third and fourth portions of the duodenum was detected on upper gastrointestinal endoscopy. Examination of a biopsy specimen revealed adenocarcinoma. Hypotonic duodenography demonstrated stenotic change in the third and fourth portions of the duodenum, and abdominal CT revealed an enhanced tumor without any metastasis or signs of local infiltration. The patient had a pancreas-sparing duodenectomy combined with lymph node dissection around the superior mesenteric artery. Reconstruction was achieved by side to side anastomosis, and an ileus tube was inserted beyond the anastomosis as an internal stent. On pathology, papillary adenocarcinoma was found at a site in the subserosa. There was no invasion of lymph and venous vessels. The postoperative course was uneventful. The patient is currently doing well without recurrence about four years after surgery. We describe this rare case of primary adenocarcinoma in the third portion of the duodenum with details of the surgical technique. The relevant literature is also disussed.

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The patient was an 87-year-old woman who had undergone laparoscopic repair of an abdominal incisional hernia with Composix Mesh (CM) at age 79 (years). Her postoperative course was uneventful, without signs of recurrence. Eight years after surgery, she complained of an exudate and malodor arising from the wound site. Exudation of intestinal fluid from a median fistula in the lower abdomen was observed. Computed tomography revealed adhesion between the CM and the intestine, and fistulography confirmed a communication with the intestine. At laparotomy, it was found that the CM had become folded to form a mass with the surrounding granulation tissue and had adhered to a large part of the intestine which had been penetrated at one point in the process of fistula formation. The CM and the fistula were resected, and the penetrated part of the intestine was sutured to close the wound. The abdominal wall was closed using the components separation technique. Our experience suggests that pathology similar to that of our patient might occur in the future in cases treated using the CM/Composix Kugel Patch. Intra-abdominal mesh fixation must be carefully and innovatively done.

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We report a rare case wherein idiopathic perforation of the small intestine occurred twice in 7 years. A 39-year-old man had a surgical history of closure of perforation of the small intestine due to small intestinal perforation of unknown cause when he was 32 years old and partial resection of the small intestine due to strangulation ileus when he was 33 years old. He complained of abdominal pain after eating lunch, and visited our hospital. He had tenderness throughout the abdomen. An abdominal CT scan revealed ascites without free air. Emergency surgery was performed based on the diagnosis of diffuse peritonitis. At the time of laparotomy, a 10-mm perforation of the small intestine was confirmed, and partial resection of the small intestine was performed. His postoperative course was uneventful. Histopathologically, the mucosa, muscular, and serous layers at the perforation had ruptured, but no special lesions suggestive of chronic inflammation were seen around the lesion. There were no other pathological findings. Therefore, he was diagnosed with idiopathic perforation of the small intestine. The histopathological findings of the specimen from the previous perforation were almost the same as those for the present perforation. Therefore, the previous perforation was also diagnosed as idiopathic perforation.

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A 59-year-old man was admitted to the hospital with a diagnosis of small bowel obstruction. Abdominal computed tomography (CT) showed intussusception caused by a tumor in the small intestine. Ileocecal resection was performed under the diagnosis of ileum-to-colon intussusceptions. The resected specimen included a 6×2 cm elevated lesion in the ileum where was 60 cm proximal to the terminal ileum. Histological findings suggested that the tumor was composed of inverted true diverticulum. On pathological findings, ectopic gastric mucosa or pancreatic organization was not observed in the mucous membrane of the small intestine. We finally diagnosed this patient with intussusception caused by inverted Meckel's diverticulum, which is relatively rare in adults. Meckel's diverticulum should be considered as one of the causes of adult intussusception, although preoperative diagnosis of this disease is difficult.

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A 33-year-old man was admitted with acute lower abdominal pain. A bulky tumor, ascites, and free air were indicated by abdominal computed tomography. We diagnosed the patient with perforative peritonitis and performed emergency surgery.
Laparotomy showed that the tumor originated from the ileocecal mesentery and infiltrated the ileum. Ileocecal resection was performed. Pathological findings showed that spindle-shaped tumor cells grew proliferously with a patternless pattern. Immunohistochemistry findings showed that tumor cells were positive for CD34 and negative for c-kit, desmin, and S-100. Therefore, we diagnosed the patient with solitary fibrous tumor (SFT). Perforative peritonitis was thought to be caused by the penetrated ileum. SFTs are uncommon mesenchymal neoplasms of ubiquitous location, observed in middle-aged adults. This is the first report about a SFT presenting with perforative peritonitis.

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Appendiceal diverticulitis is a relatively rare disease and is difficult to make preoperative diagnosis. We herein report a patient who was diagnosed with appendiceal diverticulitis after surgery under a preoperative diagnosis of acute appendicitis or mucocele of the appendix.
A 38-year-old man was referred to our hospital complaining of right lower quadrant pain. His symptom subsided with anti-bacterial treatment with a diagnosis of appendicitis. Three months later he was seen at our hospital because of recurrent right lower quadrant pain. Abdominal enhanced CT revealed a multilocular cystic lesion of the appendix. Operation was performed under a diagnosis of recurrent appendicitis or mucocele of the appendix. Intraoperative findings showed swelling of the appendix and mesoappendix. We performed appendectomy. Intraoperative histopathological examination did not show any neoplastic lesion. The final pathological diagnosis was appendiceal diverticulitis.
With a recent progression of imaging diagnosis, appendiceal diverticulitis has increasingly reported. We should bear the disease in mind as a possible differential diagnosis in treating patients complaining of right lower quadrant pain.

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A 50-year-old woman presented to our emergency department with abdominal pain. Abdominal enhanced CT showed an enhanced wall thickness with inflammation of the cecum and ascending colon ; ascites was also present. Thus, colon cancer was suspected, and the patient was emergently admitted. Colonoscopy revealed a submucosal tumor with erythema in the cecum and ascending colon. A biopsy specimen showed only inflamed cells. Enema X-ray examination showed a gradually elevated defect in the cecum and ascending colon, suggesting a submucosal tumor of the cecum and ascending colon. Atlhough a definitive diagnosis was not obtained, a malignant tumor could not be ruled out. So an iliocecal resection was performed. The patient had an uncomplicated postoperative course and was discharged 7 days after surgery. Endometriosis of the cecum was diagnosed on pathology. The patient underwent hormonal therapy to prevent recurrence. Given that the main lesion of intestinal endometriosis is located under the submucosal layer of the bowel, it is quite difficult to diagnose preoperatively. In most cases, as in this case, surgery is necessary to make a correct diagnosis.

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Causes of rectal prolapse include a long sigmoid colon, a deep pouch of Douglas, weakness of pelvic muscles, a rectocele, a rectum not fixed to the sacrum, and pelvic organ prolapse. The only curative treatment of rectal prolapse is operative. There are no guidelines for these operative procedures. We present a case of rectal prolapse caused by the rectum not fixed to the sacrum diagnosed on defecografy.
A 67-year-old man suffered since anal prolapse since childhood, which was not correctly diagnosed and was manually reduced by himself or his parents. In December 2009, he was admitted due to rectal prolapse and severe pain, which was found to be caused by the rectum not being fixed to the sacrum on dynamic defecography. The patient underwent a transabdominal rectopexy using Sudeck's procedure. Defecografy was useful for identifying the cause of the patient's condition, and in selecting an optimal operative procedure. We herein report our case and review the literature.

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A 19-year-old male had been diagnosed as having ulcerative colitis when he was a 14-year-old, but he had not been treated with salazosulfapyridine. He developed constipation and fever. On CT, wall thickness was found in the transverse colon ; a stenosis in the transverse colon was identified on barium enema studies and colonoscopy. After 2 months of conservative therapy, he underwent a laparoscopic subtotal colectomy. The resected specimen had inflammatory polyposis in the ascending and transverse colon. On pathology, crypts with regenerative-hyperplastic changes, inflammatory cellular infiltration, crypt abscesses in the lamina propia, many lymph follicles and fibrous changes between the submucosa and the subserosa were noted. There was no evidence of a non-caseous epithlioid granuloma. Therefore, neither ulcerative colitis nor Crohn's disease could be diagnosed. Thus, the patient was diagnosed as having indeterminate colitis.

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A 34-year-old woman presenting with left upper abdominal pain came to our hospital. Computed tomography scan showed intussusception in the descending colon induced by a cystic tumor of the appendix. Gastrografin enema repositioned the cystic tumor to the cecum, but, the intussusception was not completely reduced. Laparoscopy-assisted ileocecal resection and regional lymph node dissection were performed without complete reduction of the intussusception. During the laparoscopic surgery, we paid close attention to avoid intraperitoneal dissemination of neoplastic cells and mucoid material. The pathological diagnosis was mucinous cystadenocarcinoma of the appendix (SI ly1 v0 N0) which was invading the submucosal layer of the cecum. In this case, complete reduction of the intussusception may have caused pseudomyxoma peritonei. It is possible to perform laparoscopic surgery to treat mucinous cystadenocarcinoma of the appendix with intussusception. It is not necessary to reduce the intussusception completely when it is induced by cystadenocarcinoma of the appendix.

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A 64-year-old man was admitted to our hospital for abdominal pain and diarrhea. Colonofiberscopy revealed a type 2 elevated lesion in the transverse colon. Gastrointestinal fiberscopy revealed a mass in the second portion of the duodenum and a fistula between the duodenum and the colon. Computed tomography (CT) findings showed that the tumor was adjacent to the pancreatic head. Transverse colon cancer with direct invasion to the duodenum and pancreas was diagnosed, and we conducted right hemicolectomy and pylorus-preserving pancreaticoduodenectomy, and partial hepatectomy. The pathological findings were SI (duodenum), N1 (1/25), stage IIIa. There have been no signs of recurrence and the patient is living and well, as of 51 months after the operation. Although colon cancer with invasion to the duodenum is a rare condition, we experienced a case of transverse colon cancer with duodenocolic fistula with long-term survival after en bloc radical surgery. We evaluated the clinical course and outcome in six patients of colon and rectal cancer with invasion to the duodenum, and patients treated with curability A achieved long-term survival. In such cases, we believe that we should try to perform en bloc resection if curative resection is possible.

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A 48-year-old woman visited a local physician with a chief complaint of bloody stool, and lower gastrointestinal endoscopy revealed a type II tumor in the sigmoid colon. The patient was diagnosed with well-differentiated adenocarcinoma based on the biopsy and referred to our hospital. Abdominal computed tomography (CT) showed a mass, 3 cm in diameter, in the medial segment (S4) of the liver, and a diagnosis of synchronous liver metastasis was made. Surgery consisting of sigmoidectomy and left lobectomy was performed. Histopathological findings included components of invasive micropapillary carcinoma (IMPC) at the site of invasion of the sigmoid colon cancer. IMPC is a new tissue type of invasive breast cancer that was proposed in 1993 by Siraunkgul et al., and it has recently been reported in other organs as well. Reports of colon cancer presenting with IMPC components are relatively rare, and the present case is described along with a review of the relevant literature.

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A 67-year-old man visited our hospital because of bloody stools and a hard mass that prolapsed from the anus. Colonoscopy revealed a protrunding lesion with ulceration, a nodule, elevated plaques, and necrotic tissue. The tumor was located close to the anal canal over the Herrmann line from the rectum. Pathological analysis of a biopsy specimen indicated a diagnosis of poorly differentiated adenocarcinoma, and the patient was admitted our hospital. Rectal cancer was diagnosed, and abdominoperineal resection was performed. Histopathological examination of the resected specimen indicated an amelanotic melanoma(positive for S-100, HMB45, and MART-1). Up to 90% of cases of malignant melanoma that occurs in the anorectum are of melanotic tumor. Therefore, malignant melanoma can be diagnosed before surgery, and immunohistochemical staining was used for diagnosis in many cases. However, an amelanotic melanoma is difficult to diagnose because of the small amount of melanin as a result of which it does not appear black in color.

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A 64-year-old man who presented with fecal occult blood was admitted to our hospital. Colonoscopy revealed a protruded lesion with decomposition on the dental line. A biopsy sample of the lesion showed normal findings. The patient was diagnosed with mucosal prolapse syndrome (MPS), which progressed during observation. Five months after diagnosis, a biopsy showed that the lesion was ulcerated and malignant. Therefore, we performed perianal local excision of the lesion. Pathological tests revealed evidence of fibromuscular obliteration of the mucosal stroma in the anal canal, and cellular atypia beyond the scope of atypical regeneration. These results indicated well-differentiated tubular adenocarcinoma, which developed as MPS progressed. After excision, all the test results were negative, and the patient was kept under observation. At the time of diagnosis of MPS, it is important to distinguish between MPS and rectal cancer. There are few reports on the progression of MPS to cancer that is diagnosed during follow-up MPS examinations.

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We report our experience with a case of a tailgut cyst associated with rectal cancer. The patient was a 55-year-old woman. Preoperative CT scan for rectal cancer revealed an irregular-shaped tumor at the retrorectal space. A metastatic lesion to outside of the fascia propria recti was a possibility. However, abdominal MRI identified the tumor as a well-defined multilocular cystic lesion. Tailgut cyst was thus diagnosed and the transsacral approach was employed to remove the lesion.
Tailgut cysts are cystic lesions arisen in the retrorectal space and are rarely associated with rectal cancer. Accordingly we report this case together with some bibliographic comments.

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The patient was in her sixties who had worked near the operator of a lawn mower, came to our hospital with the complaint of continuing right chest pain. Chest X-ray (CXR), computed tomography (CT) and ultrasonography (US) revealed a linear foreign body embedded in the liver, which was believed to have been projected by a lawn mower. Laparoscopic removal was performed. Laparoscopic ultrasonography detected the foreign body (a wire) entirely embedded in the liver. Microwave coagulation was performed on the liver to prevent hemorrhage. Liver was manipulated by forceps at laparoscopy to search for the foreign body, which was removed without complication. The patient had an uneventful postoperative course. Intrahepatic foreign body from a projectile injury by a lawn mower is very rare. To accomplish this laparoscopic surgery, it is important to select patients who have the required indications, evaluate the possibility and use the devices optimally.

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We report a case of a 58-year-old woman who was diagnosed as having sarcoidosis 2 years previously. She was referred to our hospital because of a liver tumor. An abdominal contrast computed tomography scan showed a ring-enhanced tumor, 14 cm in diameter, in the right lobe of the liver and swollen lymph nodes in the hepatoduodenal ligament and paraaortic lesion. 18-fluorodeoxyglucose-positron emission tomography (FDG-PET) showed abnormal FDG uptake at the lymph node in the hepatoduodenal ligament, but the uptake at the paraaortic lymph node was obscure. We performed right hepatectomy and lymph node dissection, and the pathological diagnosis of the liver tumor was intrahepatic cholangiocarcinoma. No metastasis was detected in the dissected lymph nodes, and all lesions were diagnosed as sarcoid nodules consisting of epithelioid cells without caseous necrosis.

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A-45-year-old woman complaining of epigastric pain was referred to our hospital with a diagnosis of cholelithiasis. A multilocular tumor, which was 9 cm in diameter and showed slight contrast effect, was detected in the medial segment of liver. Endoscopic retrograde cholangiopancreatography revealed no filling of the cysts, with an exception of a part of the cysts that communicated with the bile duct. Mucinous cystic neoplasm (MCN) of the liver was diagnosed and, we performed an extended left hepatic lobectomy. The pathological diagnosis was MCN, showing flat, single layered cuboidal to columnar epithelium of little atypia and ovarian-type subepithelial stroma. The part of the cyst communicating with the bile duct showed loss of epithelial cells and no ovarian-type stroma. No recurrence has occurred as of 3 months after the operation. The hepatic MCN is a rare cystic tumor of the liver, and the prognosis of the patient is excellent if complete resection is possible. In our case, we had difficulty in diagnosing the tumor preoperatively because of some unusual findings in preoperative examinations.

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A cholecystogastric fistula is considered to be a rare entity. We report a case with a cholecystogastric fistula complicated by gallstone ileus. An 82-year-old man, who had taken a proton pump inhibitor for a gastric ulcer, presented with epigastralgia and vomiting. Abdominal CT showed air density and calcification in a small gallbladder. CT also revealed a calcified body, 5×3 cm in size, in the small bowel associated with a proximal dilation. The patient was initially treated conservatively with a long intestinal tube, but this failed to resolve the obstruction. Therefore, a laparotomy was done, and a gallstone 5×3 cm in size was found to be obstructing the jejunum. The gallbladder had created an adhesion between the pylorus and the round ligament. A cholecystogastric fistula was identified. Enterolithotomy combined with cholecystectomy and fistula closure was performed.

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We describe a case of intraductal papillary mucinous carcinoma (IPMC), 25 years following pancreaticojejunostomy (Partington-Rochelle). A 76-year-old man presented to the emergency unit with abdominal pain and a fever. Past medical history revealed a pancreaticojejunostomy (Partington-Rochelle) undertaken 25 years previously. Abdominal enhanced computed tomography showed a papillary cystic tumor of the pancreatic body, which had infiltrated the jejunum, showing a ‘dirty fat’ sign. Intraductal papillary mucinous neoplasm was diagnosed and emergency surgery undertaken. Surgical findings revealed a large tumor in the pancreatic body, with infiltration in the pancreaticojejunostomy anastomosis and jejunum, and a large amount of mucus accumulation. Distal pancreatectomy with D2 lymph node dissection and resection of the jejunum anastomosis was undertaken. Based on histopathological findings, IPMC was diagnosed. An investigation of the literature revealed no reports of IPMC occurring at the site of pancreaticojejunostomy anastomosis, suggesting that this is the first case in Japan.

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A 65-year-old woman underwent subtotal, stomach-preserving pancreatoduodenectomy with combined resection of the portal vein and superior mesenteric vein following preoperative chemoradiotherapy for carcinoma of the head of the pancreas. During surgery, the splenic vein and inferior mesenteric vein were resected, and marked congestion was seen throughout the stomach immediately after additional resection of the left gastric vein. It was thought that this was caused by stagnation in the left portal system, and an end-to-side anastomosis between the right gastroepiploic vein and inferior mesenteric vein was performed, which resulted in immediate improvement of gastric congestion. Contrast-enhanced computed tomography (CT) taken on postoperative day 5 showed development of collateral blood flow as follows : right gastroepiploic vein → anastomotic site → inferior mesenteric vein →left colic vein → marginal middle colic vein → middle colic vein. The patient was discharged postoperatively without delayed gastric emptying or other problems, and no symptoms such as gastrointestinal bleeding have occurred since then. The present case is reported as it suggests that anastomosis between the right gastroepiploic vein and inferior mesenteric vein is effective for marked gastric congestion during combined resection of the portal vein and superior mesenteric vein.

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We report a very rare case of a resected splenic tumor. A 30-year-old man was incidentally found to have a splenic tumor by ultrasonography during a medical examination. Ultrasonography and CT showed that the tumor was gradually increasing in size. The tumor showed high FDG accumulation on FDG-PET. Therefore, malignant disease could not be ruled out, and splenecomy was performed. On the basis of histopathological findings, the splenic solid tumor with a clear margin was diagnosed as sclerosing angiomatoid nodular transformation (SANT). SANT is a very rare tumor-forming disorder of the spleen that was initially reported in 2004. We describe our case and other SANT cases in Japan and review the relevant literature.

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A 22-year-old man was admitted to our hospital because of the sudden onset of upper abdominal pain of unknown cause in the morning. An abdominal CT scan showed ascites in the abdominal cavity and a mass in the left omentum, which was not enhanced by contrast CT, without extravasation of contrast medium. Angiographic examination of the abdomen did not indicate extravasation. From these findings intraabdominal hemorrhage caused by bleeding from the greater omentum was suspected. Vital sighs were stable, but laparoscopic operation was carried out to search the cause of the omental hemorrhage and to avoid possible risk of rebleeding. We found hematoma inside the greater omentum. Partial resection of the omentum including the left gastroepiploic vessel was done. His postoperative course was uneventful. Pathologic examination of the omentum presented no abnormal findings. Thus idiopathic omental hemorrhage was diagnosed.
We present the case with a review of the literature.

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We report a case of retroperitoneal fibrosis mimicking pancreatic metastasis of renal cell carcinoma. A 73-year-old female had a radical nephrectomy for a renal mass. On pathology, renal cell carcinoma, pT3a N0 stage III was diagnosed. Within 8 months of surgery, a control CT scan demonstrated a left retroperitoneal mass, contiguous with the pancreatic tail and splenic hilum, suggesting local relapse. The patient had a resection of the mass with a splenectomy, partial colectomy, and partial pancreatectomy en bloc. Microscopic evaluation revealed a dense collagenic tissue with a prominent inflammatory infiltrate. Immunohistochemical studies showed positive nuclear staining for β-catenin. All these findings help make a diagnosis of retroperitoneal fibrosis. Retroperitoneal fibrosis can simulate or be associated with malignancies.

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A 47-year-old man was referred to our hospital for the evaluation of a retroperitoneal tumor. The tumor 4 cm in diameter was located in the retroperitoneal space, on the left of the abdominal aorta. Computed tomography (CT) showed an enhanced solitary tumor and magnetic resonance imaging (MRI) showed a mass of iso intensity to the muscle on T1-weighted image, and of slightly high intensity on T2-weighted image. Positoron emission tomography showed abnormally high uptake of FDG in the tumor. The tumor was resected with laparoscopic surgery for the purpose of diagnosis and treatment. The operative time was 250 minutes and the total volume of bleed loss was 80ml. Histopathological diagnosis of the tumor was Castleman disease, hyaline-vascular type. Castleman disease is a benign lymphoproliferative disease first reported by Dr. Benjamin Castleman in 1954. Castleman disease most commonly affects the head, neck or mediastinum, and rarely affects the retroperitoneum. Although the tumor was hypervascular, we could easily identify and treat the feeding vessels to the tumor by magnifying under laparoscopy and perform minimally invasive surgery.

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